Giant cardiac myxoma misdiagnosed as schizophrenia: a case report

DOI: https://doi.org/10.21203/rs.3.rs-2242535/v1

Abstract

Background

Myxoma is the most common cardiac tumor and usually presents in the left atrium. Patients typically present with tightness of the chest, fatigue and lassitude. There are also cases of misdiagnosis and missed diagnosis. Improvements tend to occur with early diagnosis, and with the help of high-resolution imaging technology, such as transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and computed tomography (CT).

Case presentation:

A 59-year-old Chinese woman complained of tightness in her chest, fatigue and lassitude for eight years. She had been misdiagnosed with schizophrenia by the local rural hospital. CT confirmed a giant mass in the left atrium, and TTE revealed left atrial enlargement with an occupying lesion. Tumor resection surgery was performed under cardiopulmonary bypass. The giant tumor was partially detached during the operation, and the thrombus was removed successfully. After the operation, the mental health department of our hospital believed that the diagnosis of schizophrenia was a misdiagnosis. The patient recovered uneventfully and appeared rejuvenated after the operation. A three-year follow-up showed no adverse events since the operation.

Conclusions

A rare case of cardiac myxoma misdiagnosed as schizophrenia is presented here. When patients complain of chest tightness, we cannot forget the importance of cardiac physical examination and echocardiography. Any diagnosis of schizophrenia requires exclusion of organic disease. Careful and complete resection of the cardiac myxoma is necessary, as it may cause thromboembolism.

Background

Primary cardiac tumors are rare, with autopsy findings ranging from 0.0017–0.28%. Myxoma is the most common cardiac tumor and can typically be diagnosed using echocardiography. However, certain myxomas have rare features that can lead to misdiagnosis [1]. Approximately 95% of cardiac myxomas occur in individuals of a wide age range. However, they occur more frequently among women in the fifth or sixth decade of life [2]. We reported a 59-year-old Chinese woman with a giant left atrial myxoma misdiagnosed as schizophrenia for eight years, an incident that is quite rare.

Case Presentation

A 59-year-old Chinese woman complained of tightness in her chest, fatigue and lassitude for eight years. The doctors in the local rural hospital did not administer a TTE to evaluate her cardiac function. They simply diagnosed her with schizophrenia, since there was no organic damage that can be identified. The patient had applied for a schizophrenia certificate and used olanzapine for treatment. In recent years, her symptoms had worsened and thus came to our hospital.

Electrocardiograph showed nothing remarkable despite a ventricular premature beat. An X-ray did reveal an increase in the chest-heart ratio (Fig. 1A). After suspecting it to be cardiogenic disease and not schizophrenia, TTE and CT examinations were performed. The CT confirmed a giant mass in the left atrium (Fig. 1B, yellow arrow), while the TTE revealed a left atrial enlargement with an occupying lesion (4.87cm×7.13cm) (Fig. 1C, blue arrow).

Tumor resection was performed via a median sternotomy with cardiopulmonary bypass. During the surgery, a gelatinous and fragile mass that filled the entire left atrium and growing from the interatrial septum was noted (with a 4.5cm pedicle) (Fig. 1D, white arrow). The 10×7×3 cm mass and pedicle were successfully removed (Fig. 1E, yellow arrow). An atrial septal defect repair was completed after that. When the “Y” tube was pulled off during the surgery, blood pressure in the left radial artery suddenly dropped off, while the right radial artery and cardiac function remained normal. Since we suspected that some myxoma fragments may have fallen off, we immediately consulted with the vascular surgery department and found a tumor thrombus at the far end of the left radial artery. Embolectomy was successfully performed and two small tumor emboli were successfully removed from the left radial artery (Fig. 1E, blue arrows).

A pathological examination confirmed the final diagnosis of primary cardiac myxoma from the interatrial septum (Fig. 1F) (hematoxylin and eosin stain, ×400 magnification). The patient recovered well and appeared rejuvenated after the operation. A three-year follow-up found no adverse events since the operation. After the operation, the mental health department of our hospital believe that the patient's diagnosis of schizophrenia was misdiagnosed.

Discussion

The World Health Organization defines a cardiac myxoma as a neoplasm. The gross specimen of myxomas are polyp-like, villous, or jelly-like with a smooth surface. There are plenty of stellate cells among mucoid stroms. Seventy-five percent of myxomas occur in the left atrium, 23% in the right atrium with 2% in each of the right and left ventricles and 1% in the valve [3].

Clinical manifestations of cardiac myxomas are daedal. They can be asymptomatic in tumor size for cases of < 4cm and result in unexpected sudden death (generally caused by blood-flow obstruction or embolization) [4]. The myxoma clinically presents with intracardiac obstruction with congestive heart failure (67%), signs of embolization (29%), fever (19%), weight loss or fatigue (17%), and immunologic manifestations of myalgia, weakness, and arthralgia (5%), with almost all patients presenting with one or more of these symptoms [5]. Our patient had typical symptoms of congestive heart failure and perioperative embolization.

The diagnosis of cardiac myxoma requires TTE (or TEE) and CT before surgery. There can often be a misdiagnosis of the condition due to poor image quality or atypical myxoma. It has been confused with a thrombus and myocardial infarction [6]. Cardiac myxoma is the most common benign cardiac tumor, but many cardiac malignant tumors have been misdiagnosed as cardiac myxoma, resulting in delayed treatment. Without the help of TTE or TEE, myxomas can easily be misdiagnosed as other systemic diseases. But as far we know, a misdiagnosis of schizophrenia is rare. The misdiagnosis of the patient in this case was largely attributed to local doctors not having given her a timely cardiac examination, including auscultation and echocardiography. When patients complain of tightness in the chest, we must not forget the importance of the cardiac physical examination and TTE (or TEE).

Systemic embolization is the second-most common mode of presentation for patients with myxoma. It occurs in 30%-40% of patients. Because the majority of myxomas are left-sided, approximately 50% of embolic episodes affect the central nervous system owing to both intracranial and extracranial vascular obstruction. We reported a case of arterial embolism in the upper-left extremity. Fortunately, the radial artery blood pressure was measured in the left upper limb. Problems were found in time during the operation and the embolus was successfully removed.

Tumor resection via median sternotomy is a common method for treating myxoma. For myxoma with a villous surface, it is necessary to completely resect the tumor and prevent thromboembolism caused by the tumor.

Conclusions

A rare case of cardiac myxoma misdiagnosed as schizophrenia is presented here. When patients complain of chest tightness, we cannot forget the importance of cardiac physical examination and echocardiography. Any diagnosis of schizophrenia requires exclusion of organic disease. Careful and complete resection of the cardiac myxoma is necessary, as it may cause thromboembolism.

Abbreviations

TEE

Transesophageal echocardiography

CT

Computed tomography

TTE

transthoracic echocardiography.

Declarations

Acknowledgements

None.

Author contributions

(I) Conception, design and collection of data and figure: YW; (II) Administrative support and manuscript writing: HX. All authors read and approved the final manuscript.

Funding 

This article was funded by the National Natural Science Foundation of China, grant numbers 82200269.

Availability of data and materials

Not applicable.

Ethics approval and consent to participate

This was a case report and the requirement for an approval from the institutional review board of the First Affiliated Hospital of Zhejiang University was waived.

Consent for publication

Written informed consent of clinical detail and image publication was obtained from the patient.

Competing interests

The authors declare that there is no conflict of interests. 

References

  1. Xia LY, Zhu HL, Li RH, Pan XH, Liu B, Xu J. A rare left ventricular cardiac myxoma mimicking fibroma. J Cardiothorac Surg. 2022 Aug 26;17(1):207.
  2. Herrera C, Bruña V, Barrio JM, Cuerpo G, Fernández-Avilés F. Bayés de Luna A, Martínez-Sellés M. Atrial myxoma surgery and P-wave remodeling. Pacing Clin Electrophysiol. 2022 Sep;45(9):1160–4.
  3. Samanidis G, Khoury M, Balanika M, Perrea DN. Current challenges in the diagnosis and treatment of cardiac myxoma. Kardiol Pol. 2020 Apr 24;78(4):269–277.
  4. Liu D, Dong R. Clinical manifestation and surgical treatment analysis of five cases with biatrial myxoma. Int J Cardiol. 2017 Feb;1:228:309–12.
  5. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Med (Baltim). 2001;80(3):159–72.
  6. Wang Q, Yang F, Zhu F, et al. A case report of left atrial myxoma-induced acute myocardial infarction and successive stroke. Med (Baltim). 2018;97(51):e13451.